Coroner Finds Failure To Adequately Monitor Mother And Baby May Have Changed Outcome

The devastated parents of a baby girl who died just hours after she was born at Chelsea and Westminster Hospital say they hope lessons have been learned after an Inquest heard there was a catalogue of errors in the care provided during the mother’s labour.

Gintare Degutiene, 33, went into labour at 41 weeks’ gestation on 17 March 2015. She attended hospital but there was a long delay in transferring her to the labour ward, during which time neither she nor her baby were adequately monitored.

Having been transferred to the labour ward, the baby started to show signs of distress which were not acted upon and there were further avoidable delays in her delivery. Gintare’s baby, Emily Radavicius, was born in a very poor condition and required resuscitation.

Tragically, Emily did not respond to medical treatment and her parents were advised to withdraw treatment. Emily died in the early hours of 18 March 2015.

Ginta and her partner, Linas Radavicius, 45, instructed specialist medical negligence lawyers at Irwin Mitchell’s London office to investigate the care provided before and during the birth.

At an Inquest at Westminster Coroner’s Court today (25 February 2016), assistant Coroner Dr Shirley Radcliffe said there was clearly a failure to monitor the mother and baby adequately which may have changed the outcome.

She added: "There was certainly a missed opportunity to have a better chance of delivering Emily in a safe manner, and I think that is a tragedy."

An internal investigation conducted by the hospital concluded that the delay in transferring Ginta to the labour ward and the failure to monitor maternal progress and fetal heart rate and well-being were contributory factors in Emily’s death.

The Chelsea and Westminster Hospital NHS Foundation Trust has now apologised to Ginta and Linas for the failures in care and admitted liability for Emily’s death.

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“This is a tragic case of the death of a baby, which could have been prevented. Ginta and Linas have had a distressing time in the last year and they have been desperate for answers as to why Emily died.

“It was extremely difficult for the family to listen to the evidence given during the inquest today but they are grateful to the coroner for conducting such a thorough enquiry into Emily’s death.

“Ginta and Linas are relived that the trust has admitted liability for Emily’s death and apologised for the poor care they received.

“Unfortunately nothing can be done to change what happened in this case but the family hope that lessons will be continue to be learned from this tragic incident to ensure that no other family has to go through the heartbreak they have.

“The Inquest into Emily’s death comes a few months after Jeremy Hunt announced his aim to half the number of stillbirths and neonatal deaths in this country by 2030. The family welcome this initiative and hope that by sharing Emily’s story, they will be raising awareness of this issue and ensure it is addressed.”

Georgie Cushing (Nee Kerr-Dineen), Solicitor

Midwifery expert, Julian Sutton, told the inquest that there were a number of failings in the care provided to Ginta. He said the medication given to Ginta to induce her labour was administered by a midwife without a review by an obstetrician. The midwife was therefore acting outside of her training as it was administered without a valid prescription.

He also said there was a failure to adequately monitor Emily’s heart rate and Ginta’s observations throughout the labour, which went against maternity guidelines.

Mr Sutton said Emily’s delivery should have been accelerated when Ginta’s waters were broken and thick meconium was seen. This wasn’t done and led to an unnecessary delay in Emily’s birth.

Ginta said: “Emily was my second child and there had been no complications during my pregnancy. Linas and I have been left absolutely heartbroken by her death and feel like our world has been turned upside down.

“To lose Emily in this way has had a huge impact on our family, both emotionally and socially. The whole family has suffered and we have been trying to remain strong for each other, particularly during the Inquest into Emily’s death.

“We feel completely let down by the treatment we received at the hospital, from the very long delay when I first arrived, to the lack of monitoring of myself and Emily.

“My biggest concern is the lack of monitoring of Emily’s heart rate and the fact that her delivery was not brought forward when everything suggested she was in danger.

“I’m glad the hospital’s investigation and the midwifery expert found that there were failures in the care I was given and that we have now received an apology from the Trust.

“I can only hope that these findings will force changes in the way births are handled at the hospital so other families do not have to go through what we have in the last year.

“Nothing can turn back the clock, but knowing things have changed for the better and that the chances of this happening again are reduced for others will help us get through this terrible time.”

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